Low Back Pain and Breathing Pattern Disorders: Difference between revisions
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== Physical Therapy Management <br> == | == Physical Therapy Management <br> == | ||
Janssens et al <ref>Janssens L et al 2013 Inspiratory muscle training improves proprioceptive postural control in individuals with non-specific low back pain: a pilot study. 8th World Congress on Low Back & Pelvic Pain. 27-31 October 2013</ref> note that: | |||
Another article of Wolf E. Mehling et al, examined the effect of breathing therapy on [[Low Back Pain|low back pain]]. However changes in pain and disability were comparable to those resulting from extended [[Physiotherapy / Physical Therapy|physical therapy]]. They compared the effects of breathing therapy with the effect of [[Physiotherapy / Physical Therapy|physical therapy]]. Each group received one introductory evaluation sessions of 60 minutes and 12 individual therapy sessions of equal duration, 45 minutes over 6 to eight weeks. The breath therapy was given by 5 certified breath therapists. [[Physiotherapy / Physical Therapy|Physical therapy]] was given by experienced physical therapy faculty members in the Department of Physical Therapy and Rehabilitation Science. <br> | - NSCLBP subjects show a suboptimal (more ankle steered) proprioceptive postural control (PPC) strategy. <br>‘Healthy’ control is multisegmental – particularly involving the pelvis <br>- NSCLBP is also strongly related to respiratory disorders, and PPC is impaired in individuals with compromised respiratory function.<br>- Loading of the inspiratory muscles impairs postural control by decreasing lumbar proprioceptive sensitivity, and individuals with LBP have increased diaphragm fatiguability<br>- Intervention: breathing through an inspiratory resistance of 60% of maximal inspiratory pressure (controls breathed at 10% mip) x 30 times, x 2 daily, for 8 weeks.<br>- Compared with the control group, the inspiratory muscle training group demonstrated a more multi-segmental postural control strategy; increased inspiratory muscle strength and decrease of LBP severity. <br> | ||
<span> </span>According to following article, Laurie McLaughlin et al, breathing retraining should improve end-tidal CO2 (ETCO2), pain and function in most patients complaining of neck or back pain.<br>Poor breathing profiles were found in patients with neck or back pain: high respiratory rate, low CO2, erratic non-rhythmic patterns and upper chest breathing. These patients received awareness training and biofeedback with [[Capnography|capnograph]] and manual therapy to achieve better profiles. The number of sessions they received varied from two to fifteen sessions. Once the patient is convinced that he understands, feels in control over his breathing and is able to keep his ETCO2 within the normal range, then the breathing retraining is completed. <ref name="MC">Laurie McLaughlin a, *, Charlie H. Goldsmith b, Kimberly Coleman c. Breathing evaluation and retraining as an adjunct to manual therapy. Manual Therapy 16 (2011) 51e52 (B)</ref> | |||
Another article of Wolf E. Mehling et al, examined the effect of breathing therapy on [[Low Back Pain|low back pain]]. However changes in pain and disability were comparable to those resulting from extended [[Physiotherapy / Physical Therapy|physical therapy]]. They compared the effects of breathing therapy with the effect of [[Physiotherapy / Physical Therapy|physical therapy]]. Each group received one introductory evaluation sessions of 60 minutes and 12 individual therapy sessions of equal duration, 45 minutes over 6 to eight weeks. The breath therapy was given by 5 certified breath therapists. [[Physiotherapy / Physical Therapy|Physical therapy]] was given by experienced physical therapy faculty members in the Department of Physical Therapy and Rehabilitation Science. <br> | |||
The breath therapy sessions had the same structures. The patients had to keep their clothes on during the sessions and lie down on the massage table. With verbal intervention and skillful touch, the breath therapist learned the patients to become aware of the subtle physical sensations of the breath movements in the patient’s back. The skillful touch involved touching the patient with gentle pressure, holding, or gentle stretching at the back, neck and legs. The therapists had as goal to enhance the attention allocation by using this skillful touch. By teaching a meditative kind of attention to the patient, the therapist aimed to facilitate an emergence of an automatic pattern of subtle, unmanipulated breath movements. This skillful touch mediated a nonverbal dialogue between therapist and patient while both sensed breathing movements at the point of contact. The therapist provided verbal and nonverbal communication to allow for less restricted breath movements in the body regions where the breathing was restricted in combination with the experience of [[Low Back Pain|low back pain]] of the patient. | The breath therapy sessions had the same structures. The patients had to keep their clothes on during the sessions and lie down on the massage table. With verbal intervention and skillful touch, the breath therapist learned the patients to become aware of the subtle physical sensations of the breath movements in the patient’s back. The skillful touch involved touching the patient with gentle pressure, holding, or gentle stretching at the back, neck and legs. The therapists had as goal to enhance the attention allocation by using this skillful touch. By teaching a meditative kind of attention to the patient, the therapist aimed to facilitate an emergence of an automatic pattern of subtle, unmanipulated breath movements. This skillful touch mediated a nonverbal dialogue between therapist and patient while both sensed breathing movements at the point of contact. The therapist provided verbal and nonverbal communication to allow for less restricted breath movements in the body regions where the breathing was restricted in combination with the experience of [[Low Back Pain|low back pain]] of the patient. | ||
Revision as of 16:25, 21 April 2014
Original Editors - Jeroen Verwichte
Top Contributors - Aimee Tow, Jeroen Verwichte, Axel Antoine, Haegeman Nicolas, Charlotte Fastenaekels, Loïc Byl, Admin, 127.0.0.1, Ian Duerinckx, WikiSysop, Kim Jackson, Evan Thomas, Oyemi Sillo and Leon Chaitow
Search strategy [edit | edit source]
Databases Searched: Pubmed, PEDro, World Health Organisation (WHO),
Keyword Searches:Low Back Pain (LBP), Breathing pattern, Breathing disorder, Faulty breathing AND pain, Breath therapy AND low back pain, Low back pain AND yoga
Definition/Description[edit | edit source]
There are different definitions of low back pain:
The World Health Organization says low back pain is neither a disease nor a diagnostic entity of any sort.Low back pain refers to pain of variable duration in an area of the anatomy afflicted so often that it has become a paradigm of responses to external and internal stimuli.[1]
The Royal Dutch Society for Physical Therapy (KNGF) defines low back pain as a term that refers to ‘non-specific low back pain’, which is defined as low back pain that does not have a specified physical cause, such as nerve root compression (Lumbar Radiculopathy), trauma, infection or the presence of a tumor. This is the case in about 90% of all low back pain patients. In 80–90% of cases, patients their complaints diminish spontaneously within 4–6 weeks. Approximately 65% of patients who consult their primary care physician are free of symptoms after 12 weeks. Recurrent low back pain is common.[2]
A breathing pattern disorder is defined as hyperventilation or over-breathing that does not occur as a result of an underlying pathology. a level 2B study[3] has shown that the presence of respiratory disease such as a breathing pattern disorder is a strong predictor for lower back pain. Stronger than other established risk factors.
De Groot said a breathing pattern disorder is defined as chronic or recurrent changes in the breathing pattern, contributing to respiratory and nonrespiratory complaints. Symptoms are: dyspnoea with normal lung function, chest tightness, chest (and other musculoskeletal) pain, deep sighing, exercise induced breathlessness, frequent yawning and hyperventilation.[4]
What is defined as a normal breathing pattern:
• Abdominal, not chest breathing should initiate inhalation, which then expand outwards during inhalation.
• Lifting the chest up while breathing is faulty
• Lack of or a upwards lateral lifting pattern is faulty
• Paradoxical breathing is faulty
• Breathing that has no clavicular grooving formed by chronic chest lifting
Clinically Relevant Anatomy[edit | edit source]
The thoracic cage is formed by the spine, rib cage and associated muscles. While the spine and the ribs form the sides and the tops, the diaphragm forms the floor of the thoracic cage. The muscles connecting the twelve pairs of ribs are called the intercostal muscles, and the muscles running from the head and neck to the sternum and the first two ribs are the sternocleidomastoids and the scalenes.
Muscles used for ventilation:
- Inspiratory muscles: external intercostals, diaphragm, sternocleidomastoids, scalenes
- Expiratory muscles: internal intercostals and the abdominal muscles (expiration during quiet breathing is called passive expiration, because it involves passive elastic recoil)[5] [6]
Epidemiology /Etiology[edit | edit source]
Breathing pattern disorders are because of hormonal influences (progesterone stimulates respiration) female dominated with a female to male ratio ranging from 2:1 to 7:1
Currently, there isn’t a consensus as to the scale of breathing pattern disorders in the general population, but a pilot study [7] examined the relationship between BPD and musceloskeletal pain and showed that 75% of those examined showed faulty breathing patterns. Although interesting, this study has several limitations. It was not designed or intended to be a reliability study. Its methods have no proven reliability. Future research is needed to validate the inter-examiner reliability of the methods of assessing breathing mechanics and the criteria of normal and faulty patterns of respiration. But if this numbers reflect to the general population, there is a 3 in 4 chance that your patient will have faulty breathing patterns.
Biochemical and neurological changes because of BPD.
[edit | edit source]
The biochemical effects of BPD (such as hyperventilation) will lead to systemic respiratory alkalosis. This is characterized by the decrease in CO2 and an increase in pH. This induces vascular constriction, decreasing blood flow, as well as inhibiting transfer from hemoglobin of oxygen, to tissue cells (due to the Bohr Effect). Also there is found to be an altering of the magnesium, calcium and potassium balance. Muscle cells affected in this way will show an interfering with the motor control, normal muscular function and the pain perception.
A study [8]revealed that with Moderate hyperventilation, there will be loss of CO2 ions from neurons which stimulates neuronal activity. This causes for an increase in sensory and motor discharges, muscular tensions and spasms, speeding of spinal reflexes and other sensory disorders.
Research from Seyal et al [9] demonstrated that hyperventilation increased the excitability of the human corticospinal system
Biomechanical effects of BPD and the effects on the low back
[edit | edit source]
Spinal instability occurs when either passive or active stiffness is disturbed.
Muscle behavior alters in conditions of respiratory alkalosis and the bohr effect ensures that both hypoxia and ischemia are more likely. chronic hypoxemia reduces muscle force generation by skeletal muscles and their ability to endure fatigue. It also affects not only the metabolic paths but also changes the gain of sensorimotor reflex loops. Another study [10] found that reoxygenation improved the muscles performance but reduced motor unit recruitment. This all suggests that spinal stability is likely to be compromised by the effects of overbreathing.
BPD also affects the diaphragm wich muscle contraction produces (with participation of the back and abdominal muscles) the intra abdominal pressure that augments the stability of the back during tasks of heavy lifting or extraordinary demands. When a challenge occurs that demands the stabilizing function of the diaphragm at the same time of extraordinary respiratory demands, the diaphragm will choose the respiratory factor over the stabilizing factor, wich compromises the spinal stability.
Diagnostic Procedures[edit | edit source]
The diagnostic procedure for low back pain is mainly focused on the triage of patients with specific or non-specific low back. The triage is used to exclude specific pathology and nerve root pain.[11] Actually you can see breathing therapy as an additional therapy, but not as the main goal of your therapy.[12]
There are characteristics for recognizing and diagnosing breathing pattern disorders:[13]
• Restlessness (type A, “neurotic”)
• ‘Air hunger’
• Frequent sighing
• Rapid swallowing rate
• Poor breath-holding times
• Poor lateral expansion of lower thorax on inhalation
• Rise of shoulders on inhalation
• Visible “cord-like” sternomastoid muscles
• Rapid breathing rate
• Obvious paradoxical breathing
• Positive Nijmegen Test score (23 or higher)
• Low end-tidal CO2 levels on capnography assessment (below 35mmHg)
• Reports of a cluster of symptoms such as fatigue, pain (particularly chest, back and neck), anxiety, ‘brain-fog’, irritable bowel or bladder, paresthesia, cold extremities.
If a Patient has low back pain in combination with one of these characteristics, breathing therapy is advised.
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
BPD is diagnosed using physical assessment, a validated questionnaire (the Nijmegen) and a capnometer (measures respiratory Co2 levels)
- Nijmegen questionnaire provides a non-invasive test of high sensitivity (up to 91%) and specificity (up to 95%). a score of 23 out of 64 on the test suggest a positive diagnose of hyperventilation syndrome.
- Capnography have been shown to have a good concurrent validity when compared to arterial CO2 measures and can provide acces to this very important physiological information[14]
Because previous studies of breathing therapy have not included capnography in their research, it’s difficult to say anything about the validity of the device in function of therapy [15]
Medical Management
[edit | edit source]
add text here
Physical Therapy Management
[edit | edit source]
Janssens et al [16] note that:
- NSCLBP subjects show a suboptimal (more ankle steered) proprioceptive postural control (PPC) strategy.
‘Healthy’ control is multisegmental – particularly involving the pelvis
- NSCLBP is also strongly related to respiratory disorders, and PPC is impaired in individuals with compromised respiratory function.
- Loading of the inspiratory muscles impairs postural control by decreasing lumbar proprioceptive sensitivity, and individuals with LBP have increased diaphragm fatiguability
- Intervention: breathing through an inspiratory resistance of 60% of maximal inspiratory pressure (controls breathed at 10% mip) x 30 times, x 2 daily, for 8 weeks.
- Compared with the control group, the inspiratory muscle training group demonstrated a more multi-segmental postural control strategy; increased inspiratory muscle strength and decrease of LBP severity.
According to following article, Laurie McLaughlin et al, breathing retraining should improve end-tidal CO2 (ETCO2), pain and function in most patients complaining of neck or back pain.
Poor breathing profiles were found in patients with neck or back pain: high respiratory rate, low CO2, erratic non-rhythmic patterns and upper chest breathing. These patients received awareness training and biofeedback with capnograph and manual therapy to achieve better profiles. The number of sessions they received varied from two to fifteen sessions. Once the patient is convinced that he understands, feels in control over his breathing and is able to keep his ETCO2 within the normal range, then the breathing retraining is completed. [14]
Another article of Wolf E. Mehling et al, examined the effect of breathing therapy on low back pain. However changes in pain and disability were comparable to those resulting from extended physical therapy. They compared the effects of breathing therapy with the effect of physical therapy. Each group received one introductory evaluation sessions of 60 minutes and 12 individual therapy sessions of equal duration, 45 minutes over 6 to eight weeks. The breath therapy was given by 5 certified breath therapists. Physical therapy was given by experienced physical therapy faculty members in the Department of Physical Therapy and Rehabilitation Science.
The breath therapy sessions had the same structures. The patients had to keep their clothes on during the sessions and lie down on the massage table. With verbal intervention and skillful touch, the breath therapist learned the patients to become aware of the subtle physical sensations of the breath movements in the patient’s back. The skillful touch involved touching the patient with gentle pressure, holding, or gentle stretching at the back, neck and legs. The therapists had as goal to enhance the attention allocation by using this skillful touch. By teaching a meditative kind of attention to the patient, the therapist aimed to facilitate an emergence of an automatic pattern of subtle, unmanipulated breath movements. This skillful touch mediated a nonverbal dialogue between therapist and patient while both sensed breathing movements at the point of contact. The therapist provided verbal and nonverbal communication to allow for less restricted breath movements in the body regions where the breathing was restricted in combination with the experience of low back pain of the patient.
The physical therapy sessions had a longer duration to match the intervention of the breath therapy. In this intervention the therapists gave limited attention to diaphragmatic breathing and proprioception.
In addition to the breathing sessions, the therapists gave a home program with exercises to the patients. This home program was expected to last 20 to 30 minutes.
Results:
During the six to eight weeks of intervention, 71% of the participants in the breath therapy group showed more improvement than the physical therapy group, which only had 50% patients who showed improvement. The patients of the breathing group experienced improvement in pain intensity as it was measured with the VAS and the SF-36. There was also an improvement in the breath therapy group for the low back pain related functional disability measured with the Roland Morris score and in the Physical and emotional role components of the SF-36. The Balance improved in the breathing group, this was measured by a computerized dynamic posturography SOT. (Level of evidence 2B)
At six months follow-up after the last therapy session, there were more patients in the breath therapy group who were experiencing a relapse or exacerbation of low back pain than in the physical therapy group. 40 % of the patients of the breath therapy group had still an improvement for the VAS and 66,7 for the Roland Morris score in comparison with 45% for the VAS and 72,7% for the Roland Morris score in thephysical therapy group. [17] (level of evidence 2B)
Yoga combines exercise with achieving a state of mental focus through breathing. There is strong evidence that yoga is more effective than a self care book, in this study was no significant difference between the yoga and exercise group [18] (evidence level 1B) . There is weak evidence that yoga is more effective than physical exercises. [19] (evidence level 2B)
Key Research[edit | edit source]
One level 1B RCT [20] studied the effects of breathing therapy on chronic low back patients. Patients improved significantly with breathing therapy. The changes in standard low back pain measures of pain and disability were comparable to those resulting from high-quality, extended physical therapy
There is also a review that describes the relationship between low back pain and breathing pattern disorders[21]. The review states that there is evidence of a weak but statistically significant positive correlation between low back pain and respiratory problems. All the studies in this review were cross sectional 2A level cohort studies.
In one case serie [14] of 24 patient with low back or pelvic pain, they all showed an altered respiratory chemistry. Breathing dramatically improved with breathing retraining (all but one reached normal ETCO2 values). 75% of the patients reported improvements in pain, 50% reported improvements in functional activity. These results were both clinically important and statistically significant.
Resources
[edit | edit source]
Janssens L, Brumagne S, Polspoel K, Troosters T, McConnell A. The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain. Spine (Phila Pa 1976). 2010 May 1;35(10):1088-94. doi: 10.1097/BRS.0b013e3181bee5c3.
Janssens L, Brumagne S, McConnell AK, Hermans G, Troosters T, Gayan-Ramirez G. Greater diaphragm fatigability in individuals with recurrent low back pain. Respir Physiol Neurobiol. 2013 Aug 15;188(2):119-23. doi: 10.1016/j.resp.2013.05.028. Epub 2013 May 31.
Clinical Bottom Line[edit | edit source]
Breath therapy would provide a short-term improvement in pain and related functional limitations, but in the longer term one has to deal with a major downturn which it is not significantly better than conservative physiotherapy. Other research has shown that yoga is more effective than a self-care book, but there is only weak evidence that it is more effective than physical exercises.
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
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References[edit | edit source]
see adding references tutorial.
- ↑ Bulletin of the World Health Organization 2003;81:671-676
- ↑ National practice guidelines for physical therapy in patients with low back pain GE Bekkering PT MSc,I, VI HJM Hendriks PT PhD,I, VII BW Koes PhD,II RAB Oostendorp PT MT PhD,I, III, IV RWJG, Ostelo PT MSc,VI JMC Thomassen PT,V MW van Tulder PhD.V, KNGF-guidelines for physical therapy in patients with low back pain.
- ↑ Smith MD, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother 2006;52:11–6.(2B)
- ↑ de Groot EP 2011 Breathing abnormalities in children with breathlessness. Respiratory Reviews 12 (2011) 83–87
- ↑ B.R. Johnson, W.C. Ober, C.W. Garrison, A.C. Silverthorn. Human Physiology, an integrated approach, Fifth edition. Dee Unglaub Silverthorn, Ph.D.
- ↑ Theodore A. Wilson and Andre De Troyer. diaphragm Diagrammatic analysis of the respiratory action of the. J Appl Physiol 108:251-255, 2010. First published 25 November 2009; doi:10.1152/japplphysiol.00960.2009(A1)
- ↑ Perri MA, Halford E. Pain and faulty breathing: a pilot study. J Bodyw Mov Ther 2004;8:297–306
- ↑ Lum L. Hyperventilation Syndromes. In: Timmons B, Ley R. (eds) Behavioral and Psychological Approaches to Breathing Disorders. New York: Plenum Press; 1994.(3A)
- ↑ Seyal M, Mull B, Gage B. Increased excitability of the human corticospinal system with hyperventilation. Electroencephalography and Clinical Neurophysiology/Electromyography and Motor Control. 1998;109(3):263-267 (3B)
- ↑ Y. Jammes, M. C. Zattara-Hartmann and M. Badier .Functional Consequences of Acute and Chronic Hypoxia on Respiratory and Skeletal Muscles in Mammals. Comparative Biochemistry and Physiology Part A: Physiology, Volume 118, Issue 1, September 1997, Pages 15-22
- ↑ B. W. Koes, M. W. van Tulder, S Thomas, Diagnosis and treatment of low back pain, British Medical Journal, Volume 332, 2006 (3A)
- ↑ Nancy ZI, The Art of Breathing:6 Simple Lessons to Improve Performance, Health, and Well-Being , North Atlantic Books , 2000 , p. 182
- ↑ L. Chaitow ,Breathing Pattern Disorders and Lumbopelvic pain and Dysfunction, march 20 , www.leonchaitow.com (5)
- ↑ 14.0 14.1 14.2 Laurie McLaughlin, Charlie H. Goldsmith, Kimberly Coleman. Breathing evaluation and retraining as an adjunct to manual therapy. Manual therapy, volume 16, Issue 1, pages 51-52 Cite error: Invalid
<ref>tag; name "MC" defined multiple times with different content Cite error: Invalid<ref>tag; name "MC" defined multiple times with different content - ↑ J. S. Gravenstein,Michael B. Jaffe,David A. Paulus. Capnography: clinical aspects : carbon dioxide over time and volume. Br. J. Anaesth. (May 2005) 94 (5): 695-696. doi: 10.1093/bja/aei539
- ↑ Janssens L et al 2013 Inspiratory muscle training improves proprioceptive postural control in individuals with non-specific low back pain: a pilot study. 8th World Congress on Low Back & Pelvic Pain. 27-31 October 2013
- ↑ ↑ Wolf E. Mehling, MD, Kathryn A. Hamel,PhD, Michael Acree,PhD, Nancy Byl, PhD, PT, Frederick M. Hecht, MD, MPH. RANDOMIZED, CONTROLLED TRIAL OF BREATH THERAPY FOR PATIENTS WITH CHRONIC LOW-BACK PAIN. ALTERNATIVE THERAPIES, July/aug 2005, VOL. 11, NO. 4 (2B)
- ↑ ↑ Comparing Yoga, Exercise, and a Self-Care Book for Chronic Low Back Pain: A Randomized, Controlled Trial, Karen J. Sherman et al., Annals of internal medicine, 2005, level of evidence 1B
- ↑ ↑ Effect of Short-Term Intensive Yoga Program on Pain, Functional Disability and Spinal Flexibility in Chronic Low Back Pain: A Randomized Control Study, Padmini Tekeur et al., The Journal of Alternative and Complementary Medicine. July 2008, level of evidence 2B
- ↑ Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic low-back pain, Alternative Therapies in Health and Medicine 2005 Jul-Aug;11(4):44-52 (1B)
- ↑ Lise Hestbaek, DC,a Charlotte Leboeuf-Yde, DC, MPH, PhD,b and Claus Manniche, DrMedScc . IS LOW BACK PAIN PART OF A GENERAL HEALTH PATTERN OR s IT A SEPARATE AND DISTINCTIVE ENTITY?A CRITICAL LITERATURE REVIEW OF COMORBIDITY WITH LOW BACK PAIN. J Manipulative Physiol Ther. 2003 May;26(4):243-52. (2A)
